Patient Registration Form Name * First Name Last Name Date of Birth * MM DD YYYY Home Phone (###) ### #### Mobile Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Medicare Number * Do you have Private Health Insurance? * Yes No Name of Private Fund Membership Number Next of Kin * First Name Last Name Next of Kin Contact Number * (###) ### #### REFERRAL * Name of referring General Practitioner / Specialist Date of Referral MM DD YYYY Personal Medical Information Authorisation * I UNDERSTAND THAT THIS PRACTICE HANDLES PERSONAL INFORMATION IN ACCORDANCE WITH THE NATIONAL PRIVACY PRINCIPLES ENSHRINED IN THE PRIVACY ACT 1988 (COMMONWEALTH) AND AS OUTLINED IN THE PRIVACY STATEMENT. I CONSENT TO THE HANDLING OF MY INFORMATION BY THIS PRACTICE FOR THE PURPOSE OF PROVIDING QUALITY HEALTH CARE, ASSOCIATED ADMINISTRATIVE AND BILLING PURPOSES, AND DISCLOSURE FOR RESEARCH AND QUALITY ASSURANCE ACTIVITIES. I ALSO GIVE PERMISSION FOR MEDICAL INFORMATION TO BE OBTAINED FROM ANY OTHER SOURCE IN ORDER TO HELP WITH MY TREATMENT. YES I do authorise NO I do not authorise Thank you!Please email your referral to: reception@visc.health
